Evaluation of Immune Response and Disease Status in SLE Patients Following SARS-CoV-2 Vaccination
Izmirly, Peter M; Kim, Mimi Y; Samanovic, Marie; Fernandez-Ruiz, Ruth; Ohana, Sharon; Deonaraine, Kristina K; Engel, Alexis J; Masson, Mala; Xie, Xianhong; Cornelius, Amber R; Herati, Ramin S; Haberman, Rebecca H; Scher, Jose U; Guttmann, Allison; Blank, Rebecca B; Plotz, Benjamin; Haj-Ali, Mayce; Banbury, Brittany; Stream, Sara; Hasan, Ghadeer; Ho, Gary; Rackoff, Paula; Blazer, Ashira D; Tseng, Chung-E; Belmont, H Michael; Saxena, Amit; Mulligan, Mark J; Clancy, Robert M; Buyon, Jill P
OBJECTIVE:To evaluate seroreactivity and disease flares after COVID-19 vaccination in a multi-ethnic/racial cohort of patients with systemic lupus erythematosus (SLE). METHODS:90 SLE patients and 20 healthy controls receiving a complete COVID-19 vaccine regimen were included. IgG seroreactivity to the SARS-CoV-2 spike receptor-binding domain (RBD) and SARS-CoV-2 microneutralization were used to evaluate B cell responses; IFN-Î³ production to assess T cell responses was measured by ELISpot. Disease activity was measured by the hybrid SLE disease activity index (SLEDAI) and flares were assigned by the SELENA/SLEDAI flare index. RESULTS:Overall, fully vaccinated SLE patients produced significantly lower IgG antibodies against SARS-CoV-2 spike RBD than controls. Twenty-six SLE patients (28.8%) generated an IgG response below that of the lowest control (<100 units/ml). In logistic regression analyses, the use of any immunosuppressant or prednisone and a normal anti-dsDNA level prior to vaccination associated with decreased vaccine responses. IgG seroreactivity to the SARS-CoV-2 Spike RBD strongly correlated with the SARS-CoV-2 microneutralization titers and antigen-specific IFN-Î³ production determined by ELISpot. In a subset of patients with poor antibody responses, IFN-Î³ production was likewise diminished. Pre-/post-vaccination SLEDAI scores were similar. Only 11.4% of patients had a post-vaccination flare; 1.3% were severe. CONCLUSION/CONCLUSIONS:In a multi-ethnic/racial study of SLE patients 29% had a low response to the COVID-19 vaccine which was associated with being on immunosuppression. Reassuringly, disease flares were rare. While minimal protective levels remain unknown, these data suggest protocol development is needed to assess efficacy of booster vaccination.
"Doc, I'm Going for a Walk": Liberalizing or Restricting the Movement of Hospitalized Patients-Ethical, Legal, and Clinical Considerations
Alfandre, David; Stream, Sara; Geppert, Cynthia
When patients are admitted to the hospital, they are generally expected to remain in or within close proximity to their assigned rooms in order to promote their safety and appropriate medical care. Although there are circumstances when patients may safely leave their hospital room or floor, guidance within the medical literature for the management of patient movement within the hospital are lacking. Excessive restrictions on patient movement may be seen as overly paternalistic, while lax requirements may interfere with high quality care, patient safety and efficient hospital practice. As a result, guidance in the form of institutional policy is warranted. Such policy development should take into consideration the potential clinical, legal, and ethical concerns in balancing the competing values of patients' preferences and respect for autonomy, while ensuring high quality, safe, and efficacious medical care. This paper will provide a framework for hospitals to create institution-specific patient movement policies that are fair, systematic, and transparent.
"Just Getting a Cup of Coffee"-Considering Best Practices for Patients' Movement off the Hospital Floor
Stream, Sara; Alfandre, David
Factors Associated with Combined Do-Not-Resuscitate and Do-Not-Intubate Orders: A Retrospective Chart Review at an Urban Tertiary Care Center
Stream, Sara; Nolan, Anna; Kwon, Sophia; Constable, Catherine
BACKGROUND:In clinical practice, do-not-intubate (DNI) orders are generally accompanied by do-not-resuscitate (DNR) orders. Use of do-not-resuscitate (DNR) orders is associated with older patient age, more comorbid conditions, and the withholding of treatments outside of the cardiac arrest setting. Previous studies have not unpacked the factors independently associated with DNI orders. OBJECTIVE:To compare factors associated with combined DNR/DNI orders versus isolated DNR orders, as a means of elucidating factors associated with the addition of DNI orders. DESIGN/METHODS:Retrospective chart review. SETTING/SUBJECTS/METHODS:Patients who died on a General Medicine or MICU service (nâ€¯=â€¯197) at an urban public hospital over a 2-year period. MEASUREMENTS/METHODS:Logistic regression was used to identify demographic and medical data associated with code status. RESULTS:Compared with DNR orders alone, DNR/DNI orders were associated with a higher median Charlson Comorbidity Index (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.13-1.43); older age (OR 1.02, 95% CI 1.01-1.04); malignancy (OR 2.27, 95% CI 1.18-4.37); and female sex (OR 1.98, 95% CI 1.02-3.87). In the last 3 days of life, they were associated with morphine administration (OR 2.76, 95% CI 1.43-5.33); and negatively associated with use of vasopressors/inotropes (OR 10.99, 95% CI 4.83-25.00). CONCLUSIONS:Compared with DNR orders alone, combined DNR/DNI orders are more strongly associated with many of the same factors that have been linked to DNR orders. Awareness of the extent to which the two directives may be conflated during code status discussions is needed to promote patient-centered application of these interventions.
Lemierre's syndrome: A potentially deadly sore throat [Meeting Abstract]
Bhalla, S; Stream, S; Hauck, K
LEARNING OBJECTIVE #1: Recognize the clinical features and complications of Lemierre's syndrome. CASE: A healthy 25-year-old male presented with 8 days of progressively worsening sore throat, fever and neck swelling which were unresponsive to 2 outpatient courses of clarithromycin. On presentation, he was febrile, tachycardic, hypotensive, tachypneic and hypoxic. Physical examination was significant for a palpable left-sided neck mass, trismus, and muffled voice. Initial labs revealed a white blood cell count of 26k, creatinine of 1.9mg/dL, and serum lactate of 4.5mg/dL. The patient was intubated for airway protection, and started on antibiotics and vasopressors. Ultrasound and CT imaging revealed left tonsillar, peritonsillar, and sublingual abscesses, pulmonary septic emboli, bilateral parapneumonic effusions and left internal jugular (IJ) thrombus. Wound cultures of left tonsillar abscess grew Fusobacterium necrophorum and antibiotics were narrowed to piperacillin-tazobactam. He underwent left IJ ligation and left lower lobe lobectomy, and gradually improved and was discharged home on a prolonged course of antibiotics. IMPACT: Lemierre's syndrome is a potentially fatal disease that can cause rapid decompensation if untreated. When a young adult presents with worsening symptoms of acute pharyngitis, one must have a high suspicion for this disease in order to diagnose and treat it early. DISCUSSION: Lemierre's syndrome is a rare and serious disease entity that primarily affects healthy young adults with an incidence of 1 in 1 million and a mortality rate of 4-12%. It involves oropharyngeal fusobacteriuminfection that can form abscesses and internal jugular thrombophlebitis. IJ thrombophlebitis results in bacteremia with septic emboli, commonly to the lungs and joints. The prevalence of Lemierre's syndrome has been rising in recent years due to more judicious use of antibiotics for acute pharyngitis.2 This is also attributed to rising resistance of fusobacterium to macrolides that are often prescribed for pharyngitis, as illustrated by our patient who was initially treated with clarithromycin
Linked Do-Not-Resuscitate (dnr) And Do-Not-Intubate (dni) Orders And Factors Associated With Dni Orders: A Retrospective Chart Review At An Urban Tertiary Care Center [Meeting Abstract]
Stream, S; Nolan, A; Kwon, S; Constable, C
Linked Dnr and Dni Orders and Factors Associated with Intubation: A Retrospective Chart Review at an Urban Tertiary Care Center [Meeting Abstract]
Stream, Sara; Nolan, Anna; Kown, Sophia; Constable, Catherine
Linked Dnr And Dni Orders And Factors Associated With Intubation: A Retrospective Chart Review At An Urban Tertiary Care Center [Meeting Abstract]
Stream, S; Nolan, A; Constable, C